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Home My WebLink AboutApplication and WC� �� TOWN OF YARMOUTH BOARD OF HEALTS �Y�- �'� APPI.ICATION FOR LTCENSE/PtERNIIT-�410 �� b, fHEAL1 H Ut�i • * Please complete form and attach all necessary`:dacur�en�c=-�y Decemb Failure to do so will result in the retum of ypur applicatio pac cet. - ._._._..__ NAME OF ESTA$LISHMENT:_ ��\� ��,s-,�� TEL. #�- '15=�� LOCATION ADDRESS: MAILING ADDRES5: , OWNER NAME: ' ' D F or CORPORATION NAME IF A PLICABLE): "��j�'�� MANAGER'S NAME; �;� ��r�•c� TEL. # -1'�� _—�� MAILING ADDRESS:�`�`� � ��,�.�,��,,��j�,S`CC\'A O`�,\.� ..�..,..�._.,_._.:.,,...�.�.�.�._�,.._._ POOL CERTIFICATIONS: The pool supervisor must be cerrified as a Pool Qperator,as reqaired by State law. Please list the designated Paol Operator(s) and attach_a copy of the certification to this form.__ , � 1• 2. � Pool operators must list a minimum of two em loyees currently certified in basic water safety,standard First A.id and Community Cazd.iapulmonary Resuscitarion(�PR). Please list these employees b�low aud attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3: �}, FOOD PROTECTION�vIANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification ta this application. The Health Department will not use past years'records. Yoa must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: - - ----- _ . _ . _ - _ _ _ _ Each food establishment must have at least one Perso� In Charge (PIC) on site during hours of operation. 1. 2, HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all rimes. Please list your employees trained i�anti-choku�g procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. . 2. _ _ 3. _ q.. : RESTAURANT SEAT'ING: TOTAL# I 11r�I��I��A�q � OFF'�CE US� ONLY LODGING: LIC�IVSE REQUIRED FEE PERMIT# LICENSE,REQUIRED FE$ PERMIT# LICENS�REQUIRED FEE PERMIT# _BBcB $55 �CABIN $55 _MOTfiL $55 _,_,_INN $55 �CAMP �55 �SWIM!vIINGPOOL $80ea. _L4DGE $55 �TRAILERPATtK $105 WI3IRLPOOL $80ea. FOOD 5ERVICE: LICENS�REQUIRED FEE P�RMIT# LICENSE REQUIRED �'�E PERMIT# LICENSE REQUIRED FEE PERMIT# „�0-100 SEATS $85 _.,.GONTINENTAL $35 NON-PROFIT �30 >100 SEATS $160 �COMMON VIC. $60 ____WHOLESALE �80 RETAIL SERVICE: -�.RESID.KITCHEN �SO LICENSE REQLTIRED FEE PERMTf# LICENSE REQUTRED FEE FERMIT# LICENSE REQUI1tED �'EE PERMIT#i �,<50 sq.f�. �50 Q�O,� >25,000 sq.ft. $225 VENDING-fi00D $25 ,�,_<25,000 sq.ft. $80 ._,.FROZEN DESSERT $40 TOBACCO $55 NAME CHANGE: sis AMOUNT DUE _ $ Sa.00 � •*"*"PLEASE TURN OVER AND COMPLETE OTIiER SIDE OF FORM**"** NOV � 3 1009 f � � { ADMINISTRATION s. , � , .""` . , Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of any license ar pernut to operate a business if a person or company does not have a Certificate of Worker's Gompensation Insurance. THE ATTACHED STAT'E WURKER'S COMPENSATIUN INSURANCE , AFFIDAVIT MUST BE COMPLET"ED AND SIGNED,OR CERT. OF INSURANCE ATTACHED . __. _ . OR WORKER'S COMP. AFFIDAVTT SIGNED AND ATTACHED � 4 Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: XES NO M01'ELS AND OTHER LCIDGING ESTABLISHMENTS � � � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinaril�and customarily associated with motel and hotel use. I Transient occupants must have and be able to demanstrate that they maintain a principal place of residence eLsewhere. � Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an � aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or s dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy ; Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transiart. � � POQL5 E � POUL OPENING:.All swimming,wading and whirlpools which ha.ve been closed for the season must be ins ! by the Health Department�prior to opening. Contact the Health Departmem to schedule the inspection three(� ' pnor to opening.PLEASE NO�:People aze NOT allowed ta sit m the pool area until the pool has been inspected and opened. POOL WATER TES7'ING: The water must be tested for pseudomonas,total coliform and standard plate count � by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly ; thereafter. - i PUOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closin�. i FOOD SERVICE � CATERING POLICY: Anyone who caters within the Town af Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the � Health Department. ; Frozen desserts must be tested on a monthly basis by a State certified lab. Test results ' FROZEN DESSERTS: ' must be sent to the Health Department. Failure to do so will result �n the suspension or revocat�on of qour Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board afHealth. ; i OUTDOOR COO�TG: � Outdoor cooking, re aration,or disp�ay of any food product by a retail or food seivice establishment is prohibited. --- -- . __ - -- 4 NOTICE:Pernvts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ; TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. � ALL RENt)VATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY T'I�BOARn OF HEALTH PItIOR TO COMIVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. . -� DATE: \\��5��_ SIGNATURE: PRINT NAME&TITLE: 09l25/09 .:,.�� i l ��.YA�� TOWN OF YARMOUTH . � � [ 0 � '"3 ll46 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 � MATTACMEES� � � h��Ap011AtE��'��j Telephone (508) 398-2231,Ext. 241 — Fa�c (508) 760-3472 B O A R D O F H E A L T H February 17, 2010 (��[�0�VJ��p Mr. Philip Baroni FEB 2 3 2010 d/b/a Mill Stores HERL I t-r utr�i�. 270 Communication Way, Bldg. #6 Hyannis, MA 02601 Re: 2010 Permit A�plication _ - - _ __ _ - _ _ --_ -— ---_ _ - - Mill Stores, 39 Route 28, West Yarmouth ' Dear Mr. Baroni, Thank you for submitting the 2010 application for your retail food service permit issued through the Health Department. However, prior to issuing the license, we need you to fully complete the enclosed worker's compensation affidavit form. Please complete the highlighted section of the enclosed form and return it to our office at your earliest convenience. As soon as our office receives the completed ai�idavit form,we will be able to issue the license to you. If you have any questions on the above, please feel free to contact the Health Department at (508)398-2231, e�. 241. Thank you for your anticipated cooperation. Sincerely, � + Mary Alice Florio --____Princi�al_U�pattment Acsictant _- ---- _ , /maf enc. cc: file FEB 1 9 �;10 ; �� Printed on ( Recycled L 3 Paper � � � . � �c�s E l�v a� �o,er-, -_ � � The eommonwealtk of Mrrssachusetts Tt� ��}{�r►.�o�- {d�-t.-(t� ��: � ' � ' Department of Indushzal Accidents �� 6 �.�.� Zg i ' NA��f � � Sovn+�/A�R.M.o�r� �} ULb6� 600 Washingto�Street, 7`�'Floor � ' ' Boston,Mass. 02111 � + Workers'Compeosation Iosersace Affdavih BaildiHg/plambiag/Etectrical Coatractors t iwfo�matts�� pie�e pRINT le�ibl� name: ��\�� address: �� '�V I ciri�.. \A �3Y�\C�_� siate• 1c`Z� �� ZID'C �A\�DIIOLC# ��_�� WOI�C Slte IOC3t1011��dRSS): � . Q I am a hom�wner perfornung all work myself. Project Type: �New Constructi�Ditemodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition , �I am an employer providing workc�'compensation for my anpbyees wodcins�this job. i y .��''1�C��1��'� �� "�c�� __ _ _ - _ __ _ : - - _ _ - -- cems�a we.e- '��"� �`'�� aa�: � .o .��-��-�c'�,�`�j �;e.-: c��.'n ��'�-��"� n�ea�#- ius �. - �... _ _ .._t=. -v.. �;,:; � ,:-:} : . . , ..::: ,. ,k:. ., ..�. .�;, .-� Y„..,;:��..�� .�..� � , � ❑ I am a sole propriecor,ge�eral costractar,or homeowaer(circle o�)and h$ve}vred the comractas listed bebw wlw have the foliowing workers'compeosation polices: � CO�biYY I#m!' : � .. . : � �� . . . � .. � . . � . . . . . . . . .. �l8f1 - . . . . . . . � . . � . . CI�' DbOa!�' - . d. � . • , _ . .oa,._,r:.:':a+,$ �. .:. . . ._ . _ .. . . . .. ... . .. ._ _ <t 4; :r.t��:� 'r...:'�s'e' ��.3 . �Y�' �' � ; � : . . . . . .��. . . . . _ . ' . . - . ..____ .. __ . . . .—_._ ____—_. -. .-_- .—._— _. _ . . _ . �..... __ _ . - _ : .. .. .. .. . .„. .. . _ - . . . . _ . ,. . o .<�.-. . .._. . . . " -�.::: .:.:;�. . �.�:f3;; "d.:£��sr�a..'.3-_<�'` �.'-i...a�,��s�:�. k'��=��r��f�'�-�.MP.'�`-��i.u_,.r . . .. . . . . . ::.:� . FaiM+e b aeeae a►eraye aa reqind o�v Seetl�ZSA�11��_I�_�k�ts 1�Lr��fai�ial pnal�es�f i fe_�µ�as1,SM�M a�dFar ___ — --- we]�ns'vptdea�at as we6 as d►i�is tre to�s�f a 3T01'WORK ORDER a�d a�te�t i18�.N a d=y asai�t�e. 1 asdee�ud tlut a c�p��[�a�h�t�ay be fervuded ts f`e O�ce�[la�ptl�s�f 1Ye INA tor eo�sra�e�. L 10 barrby ceKijy xAder dYe Pa�s�/uedti�s ofP�+7+a!'tlFet dYe twferrwr�ien prAv�e�abaae ir lrr�e rt�d oen+erx _ _ . , �. ��- -. �,, . ... n . . .. ,. . . ,p,.., . � F 3,.�,�.: �,,., s .- - � . _., _ < 3 �� .. ., �.,_. ,- �..V,. r : r.K ,�:, ., . �.� ��; � . _� . _> � . �,, � � - � . . �- �,> ��_ ,, ;, -- �. r,a° � ._. ��, ' �;� ,, g�` ,._ �„, � � ,� offidal ate wly do ast write i�t�arn te be ps�Plefed bY dtp�r Mws��ial eilT�r t�wa: �-p�iG6ome/ f-LR�i1�.�� ❑eiect i[�sedhle�e�psex b reqi�ed . _, �B�a�+d QSdxfinea's A�oe . e"hd pi�..e�- �� tn.�iod s��DOOC Nov a 3 z�